Accuracy of injury coding under ICD-9 for New Zealand public hospital discharges

Facial Fractures in Indigenous and Non-indigenous Populations of South Australia

INTRODUCTION

Maxillofacial trauma in indigenous populations is complex with sociocultural factors, access to health care, and poorer general health issues that impact outcomes. Assaults and road traffic accidents are disproportionately experienced by indigenous persons compared with non-indigenous.

METHODS

A retrospective review was conducted from January 2012 to January 2017 at the Women and Children's Hospital and Royal Adelaide Hospital, Adelaide. All maxillofacial fractures that attended or were referred to the unit were included in this study. The primary objective was to analyze epidemiological trends of facial fractures and clinical outcomes in the South Australian indigenous and non-indigenous populations.

RESULTS

Maxillofacial fractures in indigenous persons were less than in non-indigenous (31.2 versus 38.2 y, P < 0.001) with 3.8 odds of a facial fracture. Assault was 2.9 times more likely to result in a facial fracture, falls 40.9% less likely, and sports 29.4% less likely compared with non-indigenous ( P < 0.001). Alcohol-related facial fractures had significantly higher rates [odds ratio (OR = 3.8)] compared with non-indigenous. Indigenous from most disadvantaged areas and very remote areas also had significantly higher odds of a facial fracture. Indigenous persons had higher operative rates (OR = 2.8), postoperative complications (OR = 3.1), and a 3.7-day mean difference for the length of stay (6.6 versus 2.9 d, P < 0.001).

CONCLUSIONS

Indigenous people are more likely to experience facial fractures from assault resulting in mandibular fractures, whereas non-indigenous people are likely to have sport or fall-related midface fractures. Young indigenous women from outer regional and very remote areas have greater odds of facial fractures caused by assault and alcohol with higher operative rates, postoperative complications, and extended length of stay.

Firearm injury epidemiology in children and youth in Ontario, Canada: a population-based study

BACKGROUND AND OBJECTIVE

Despite firearms contributing to significant morbidity and mortality globally, firearm injury epidemiology is seldom described outside of the USA. We examined firearm injuries among youth in Canada, including weapon type, and intent.

DESIGN

Population-based, pooled cross-sectional study using linked health administrative and demographic databases.

SETTING

Ontario, Canada.

PARTICIPANTS

All children and youth from birth to 24 years, residing in Ontario from 1 April 2003 to 31 March 2018.

EXPOSURE

Firearm injury intent and weapon type using the International Classification of Disease-10 CM codes with Canadian enhancements. Secondary exposures were sociodemographics including age, sex, rurality and income.

MAIN OUTCOMES

Any hospital or death record of a firearm injury with counts and rates of firearm injuries described overall and stratified by weapon type and injury intent. Multivariable Poisson regression stratified by injury intent was used to calculate rate ratios of firearm injuries by weapon type.

RESULTS

Of 5486 children and youth with a firearm injury (annual rate: 8.8/100 000 population), 90.7% survived. Most injuries occurred in males (90.1%, 15.5/100 000 population). 62.3% (3416) of injuries were unintentional (5.5/100 000 population) of which 1.9% were deaths, whereas 26.5% (1452) were assault related (2.3/100 00 population) of which 18.7% were deaths. Self-injury accounted for 3.7% (204) of cases of which 72.0% were deaths. Across all intents, adjusted regression models showed males were at an increased risk of injury. Non-powdered firearms accounted for half (48.6%, 3.9/100 000 population) of all injuries. Compared with handguns, non-powdered firearms had a higher risk of causing unintentional injuries (adjusted rate ratio (aRR) 14.75, 95% CI 12.01 to 18.12) but not assault (aRR 0.84, 95% CI 0.70 to 1.00).

CONCLUSIONS

Firearm injuries are a preventable public health problem among youth in Ontario, Canada. Unintentional injuries and those caused by non-powdered firearms were most common and assault and self-injury contributed to substantial firearm-related deaths and should be a focus of prevention efforts.

Vitamin D status at birth and acute respiratory infection hospitalisation during infancy

BACKGROUND

Hospital admission for acute respiratory infections (ARIs) during early childhood is a global public health concern. Vitamin D deficiency is prevalent during pregnancy and infancy. Evidence indicates that vitamin D supplementation prevents ARIs.

OBJECTIVES

To determine whether vitamin D deficiency at birth is associated with ARI hospitalisations during infancy.

METHODS

We performed a nested case-control study in children aged 0-12 months. Cases had ≥1 ARI hospitalisation and 4 controls were individually matched to each case. Newborn 25(OH)D concentration was measured on dried blood spots using two-dimensional liquid chromatography-tandem mass spectrometry. Hospital admissions were measured using health care records. Median serum 25(OH)D concentration in cases and controls was compared, and covariates of ARI hospitalisation during infancy were assessed using conditional logistic regression analysis.

RESULTS

Six per cent of the cohort (n = 384) had an ARI hospitalisation during infancy, and 1536 controls were matched to cases. Median DBS [25(OH)D] was lower among ARI cases than controls (46 nmol/l vs. 61 nmol/L). Median 25(OH)D levels were lower for those hospitalised ≥2 times (47, IQR 36, 58) vs. those hospitalised once (52, IQR 42, 62) vs. the controls and also lower for those who stayed in the hospital for ≥3 days (45, IQR 36, 54) vs 1-2 days (48, IQR 38, 59) compared to the controls. After adjustment for season of birth and covariates describing demographic, antenatal, perinatal, and infant characteristics, DBS 25(OH)D concentration (<50 nmol/L) at birth was associated with increased odds of ARI hospitalisation during infancy (odds ratio 2.20, 95% confidence interval 1.48, 2.91).

CONCLUSIONS

Vitamin D deficiency at birth is associated with increased odds of ARI hospitalisations in infants. The findings have implications for a developed country like New Zealand where vitamin D supplementation is not routinely recommended and the burden of ARI hospitalisation in young children is high.

Preoperative Sedative-hypnotic Medication Use and Adverse Postoperative Outcomes

OBJECTIVE

To determine the association between preoperative benzodiazepine and nonbenzodiazepine receptor agonist ("Z-drugs") use and adverse outcomes after surgery.

BACKGROUND

Prescriptions for benzodiazepines and Z-drugs have increased over the past decade. Despite this, the association of preoperative benzodiazepines and Z-drug receipt with adverse outcomes after surgery is unknown.

METHODS

Using the Optum Clinformatics Datamart, we performed a retrospective cohort study of adults 18 years or older who underwent any of 10 common surgical procedures between 2010 and 2015. The principal exposure was one or more filled prescriptions for a benzodiazepine or Z-drug in the 90 days before surgery. The primary outcome was any emergency department visit or hospital admission for either (1) a drug related adverse medical event or overdose or (2) a traumatic injury in the 30 days after surgery.

RESULTS

Of 785,346 patients meeting inclusion criteria, 94,887 (12.1%) filled a preoperative prescription for a benzodiazepine or Z-drug. From multivariable logistic regression, benzodiazepine or Z-drug use was associated with an increased odds of an adverse postoperative event [odds ratio 1.13; 95% confidence interval: 1.08-1.18). In a separate regression, coprescription of benzodiazepines or Z-drugs with opioids was associated with a 1.45 odds of an adverse postoperative event (95% confidence interval: 1.37-1.53).

CONCLUSIONS

Preoperative benzodiazepines and Z-drug use is common and associated with increased odds of adverse outcomes after surgery, particularly when coprescribed with opioids. Counseling on appropriate benzodiazepine and Z-drug use in advance of elective surgery may potentially increase the safety of surgical care.

Risk factors of unintentional injury among children in New Zealand: a systematic review

OBJECTIVE

To identify contemporary studies investigating multifaceted and inter-linked contributory frameworks for unintentional injuries among children in New Zealand.

METHODS

A literature review was performed in seven databases. Studies published in English up to February 2020 reporting risk factors for child injury in New Zealand were included. Eligible study designs included: cohort, case-control and case-crossover studies. The quality of studies was assessed using the GATE frame tool. The PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalyses) reporting guidelines were followed.

RESULTS

Thirteen studies fulfilled the inclusion criteria, dating from 1977 to 2008. The factors associated with child injury (0 to 14 years) included socioeconomic disadvantage, number of children, younger maternal age and sole parents. Vehicle speed and traffic volume were associated with an increased risk of driveway-related pedestrian injury.

CONCLUSION

The review findings have reinforced the need for cross-agency action to address the social determinants of child injury. Implications for public health: Contemporary longitudinal studies are needed to assist in understanding how the interactions between children, family and their wider societal context affect their risk of experiencing injury over time.

Unintentional firearm deaths in the United States 2005-2015

Background

Unintentional gun death occurs four times more often in the United States than other high-income countries. Research on these deaths typically has a narrow scope. We believe this is the first study describing the circumstances of these deaths in the United States that covers more than a single state or municipality.

Methods

We use data on all unintentional firearm fatalities in the sixteen states reporting to the National Violent Death Reporting System (NVDRS) for all years 2005–2015. Our final count of unintentional firearm deaths in these states and years is 1260. The detailed nature of the data allows us to categorize and compare the circumstances of the incident.

Results

We estimate 430 unintentional firearm fatalities in the United States per year. The rate is highest for older children to young adults, ages 10 to 29, and the vast majority of the victims are male. Common circumstances include playing with the gun (28.3% of incidents), thinking the gun was unloaded (17.2%), and hunting (13.8%). The victim is suspected to have consumed alcohol in nearly a quarter of the deaths and in 46.8% of deaths among those aged 20–29.

Conclusions

Certain circumstances, such as consuming alcohol, playing with the gun, and hunting, are common settings for unintentional firearm deaths. Firearm safety instructors, firearm manufacturers, and firearm owners can all contribute to preventing these deaths.

Data Governance in the Health Industry: Investigating Data Quality Dimensions within a Big Data Context

In the health industry, the use of data (including Big Data) is of growing importance. The term ‘Big Data’ characterizes data by its volume, and also by its velocity, variety, and veracity. Big Data needs to have effective data governance, which includes measures to manage and control the use of data and to enhance data quality, availability, and integrity. The type and description of data quality can be expressed in terms of the dimensions of data quality. Well-known dimensions are accuracy, completeness, and consistency, amongst others. Since data quality depends on how the data is expected to be used, the most important data quality dimensions depend on the context of use and industry needs. There is a lack of current research focusing on data quality dimensions for Big Data within the health industry; this paper, therefore, investigates the most important data quality dimensions for Big Data within this context. An inner hermeneutic cycle research approach was used to review relevant literature related to data quality for big health datasets in a systematic way and to produce a list of the most important data quality dimensions. Based on a hierarchical framework for organizing data quality dimensions, the highest ranked category of dimensions was determined.

Combined effects of four major geriatric syndromes on adverse outcomes based on Korean National Health Insurance claims data

AIM

Geriatric syndromes are common among older individuals, and can affect their health and quality of life. The present study aimed to determine if combinations of geriatric syndromes affected adverse outcomes among older Koreans.

METHODS

Korean national health insurance data were collected for a cohort of 5 058 720 individuals who were aged ≥65 years in 2008. The same data source was used to follow these individuals until 2015. Diagnostic codes were used to assess four major geriatric syndromes (delirium, fall-related fractures, incontinence and pressure ulcers) and adverse outcomes (mortality and nursing home institutionalization).

RESULTS

The prevalence of geriatric syndromes was 0.3% for delirium, 3.49% for fall-related fractures, 1.08% for incontinence and 0.82% for pressure ulcers. All four geriatric syndromes were associated with increased risks of institutionalization (adjusted hazard ratio [aHR] 2.18, 95% CI 2.08-2.17 for delirium; aHR 1.59, 95% CI 1.58-1.60 for fall-related fractures; aHR 1.43, 95% CI 1.41-1.44 for incontinence; and aHR 2.51, 95% CI 2.47-2.55 for pressure ulcers) and increased risks of mortality (aHR 2.13, 95% CI 2.08-2.17 for delirium; aHR 1.41, 95% CI 1.40-1.42 for fall-related fractures; aHR 1.09, 95% CI 1.07-1.10 for incontinence; and aHR 3.23, 95% CI 3.20-3.27 for pressure ulcers). The aHR for institutionalization were 1.64 (95% CI 1.63-1.65) for one geriatric syndrome, 2.40 (95% CI 2.35-2.44) for two coexisting geriatric syndromes and 2.56 (95% CI 2.35-2.74) for three coexisting geriatric syndromes. The aHR for mortality were 1.52 (95% CI 1.51-1.53) for one geriatric syndrome, 2.36 (95% CI 2.32-2.40) for two coexisting geriatric syndromes and 2.90 (95% CI 2.72-3.09) for three coexisting geriatric syndromes.

CONCLUSIONS

Delirium, fall-related fractures, incontinence and pressure ulcers were associated with increased risks of institutionalization and mortality. The magnitude of these risks increased with increasing numbers of coexisting geriatric syndromes. Geriatr Gerontol Int 2018; 18: 1463-1468.

The Costs of Fall-Related Injuries among Older Adults: Annual Per-Faller, Service Component, and Patient Out-of-Pocket Costs

OBJECTIVE

To estimate expenditures for fall-related injuries (FRIs) among older Medicare beneficiaries.

DATA SOURCES

The 2007-2009 Medicare claims and 2008 Health and Retirement Study (HRS) data for 5,497 (228 FRI and 5,269 non-FRI) beneficiaries.

STUDY DESIGN

FRIs were indicated by inpatient/outpatient ICD-9 diagnostic codes for fractures, trauma, dislocations, and by e-codes. A pre-post comparison group design was used to estimate the differential change in pre-post expenditures for the FRI relative to the non-FRI cohort (FRI expenditures). Out-of-pocket (OOP) costs, service category total annual FRI-related Medicare expenditures, expenditures related to the type of initial FRI treatment (inpatient, ED, outpatient), and the risk of persistently high expenditures (4th quartile for each post-FRI quarter) were estimated.

PRINCIPAL FINDINGS

Estimated FRI expenditures were $9,389 (95 percent CI: $5,969-$12,808). Inpatient, physician/outpatient, skilled nursing facility, and home health comprised 31, 18, 39, and 12 percent of the total. OOP costs were $1,363.0 (95 percent CI: $889-$1,837). Expenditures for FRIs initially treated in inpatient/ED/outpatient settings were $21,424/$6,142/$8,622. The FRI cohort had a 64 percent increased risk of persistently high expenditures. Total Medicare expenditures were $13 billion (95 percent CI: $9-$18 billion).

CONCLUSIONS

FRIs are associated with substantial, persistent Medicare expenditures. Cost-effectiveness of multifactorial falls prevention programs should be assessed using these expenditure estimates.

Claims-based Identification Methods and the Cost of Fall-related Injuries Among US Older Adults

OBJECTIVES

Compare expenditures of fall-related injuries (FRIs) using several methods to identify FRIs in administrative claims data.

RESEARCH DESIGN

Using 2007-2009 Medicare claims and 2008 Health and Retirement Survey data, FRIs were identified using external-cause-of-injury (e-codes 880/881/882/884/885/888) only, e-codes plus a broad set of primary diagnosis codes, and a newer approach using e-codes and diagnostic and procedural codes. Linear regression models adjusted for sociodemographic, health, and geographic characteristics were used to estimate per-FRI, service component, patient cost share, expenditures by type of initial FRI treatment (inpatient, emergency department only, outpatient), and total annual FRI-related Medicare expenditures.

SUBJECTS

The analysis included 5497 community-dwelling adults ≥65 (228 FRI, 5269 non-FRI individuals) with continuous Medicare coverage and alive during the 24-month study.

RESULTS

The 3 FRI identification methods produced differing distributions of index FRI type and varying estimated expenditures: $12,171 [95% confidence interval (CI), $4662-$19,680], $5648 (95% CI, $3819-$7476), and $9388 (95% CI, $5969-$12,808). In all models, most spending occurred in hospital, outpatient, and skilled nursing facility (SNF) settings, but greater proportions of SNF and outpatient spending were observed with commonly used FRI identification methods. Patient cost-sharing was estimated at $691-$1900 across the 3 methods. Inpatient-treated index FRIs were more expensive than emergency department and outpatient-treated FRIs across all methods, but were substantially higher when identifying FRI using only e-codes. Estimated total FRI-related Medicare expenditures were highly variable across methods.

CONCLUSIONS

FRIs are costly, with implications for Medicare and its beneficiaries. However, expenditure estimates vary considerably based on the method used to identify FRIs.

Predictors of 2010-2011 Michigan Medicaid Beneficiary Adverse E-Code Health Care Encounters

To inform Medicaid medication management and public health policymaking, the authors analyzed the major predictive factors influencing program-approved therapeutic use or poisoning E-coded encounters leading to emergency department visits and hospital admission for the totality of Michigan Medicaid beneficiaries during a 12-month 2010-2011 period. The analytic cohort was composed of 26,134 approved E-code encounters submitted for 19,865 discrete Michigan Medicaid beneficiaries.More than 1% of all beneficiaries experienced at least one adverse medication/agent-related E-code encounter during the period. More such encounters and costlier approved encounters were recorded female subjects, African Americans, dually eligible adults, urban elderly, those with fee-for-service Medicaid coverage, and those residing in urban-density counties.Especially notably for patient safety policymakers, more than 9% of total E-coded encounters for children and adults were primarily attributed by providers to likely preventable poisoning causes such as exposure to household cleaning agents/gases, cosmetic products, illicit drug/alcohol, or secondary tobacco smoke. Encounter costs for the total sample totaled $37 million but ranged considerably up to more than a quarter million dollars.In view of the future expanding Medicaid-covered beneficiary cohorts, the authors propose several key patient safety/public health policy implications for researchers and policymakers striving to serve lower-income health care consumer groups.

Increasing rates of pelvic fractures among older adults: The Netherlands, 1986-2011

BACKGROUND

age-related issues are expected to rise in the coming decades. Osteoporosis, falls and fractures are major public health issues among elderly. Pelvic fractures are associated with a serious morbidity and hospitalisation rate. We therefore performed a study to determine trends in incidence and age-specific rates of pelvic fracture-related hospitalisations among elderly (≥65 years).

METHODS

a secular trend analysis of all hospitalisations due to a pelvic fracture among older adults, using the National Medical Registration, 1986-2011, The Netherlands.

RESULTS

the total number of hospitalisations due to a pelvic fracture increased from 887 in 1986 to 2,013 admissions in 2011 (127% increase). The overall age-adjusted incidence rate increased from 5.19 in 1986 to 7.14 per 10,000 population in 2011 (37.5% increase). The incidence rate increased with age and was higher for females. The Percentual Annual Change was 1.2% (95% CI: 0.9;1.5) for older males, and 1.0% (95% CI: 0.9;1.2) for females, respectively. The mean length of hospital stay decreased between 1991 and 2011 to 12.0 days (53.4% decrease). The total number of hospital-bed-days decreased from 29,002 days in 1991 to 17,283 days in 2011 (40.4% decrease), despite an increase in absolute number of admissions.

CONCLUSION

absolute numbers and incidence rates of pelvic fractures are increasing among the older Dutch population. Considering the fact the general population is growing older, an increasing number of elderly suffer from pelvic fractures. Attention on osteoporosis screening and prevention of falls in elderly remains important, in order to limit-related healthcare costs in the future.

Internationally comparable diagnosis-specific survival probabilities for calculation of the ICD-10-based Injury Severity Score

BACKGROUND

The International Statistical Classification of Diseases, 10th Revision (ICD-10)-based Injury Severity Score (ICISS) performs well but requires diagnosis-specific survival probabilities (DSPs), which are empirically derived, for its calculation. The objective was to examine if DSPs based on data pooled from several countries could increase accuracy, precision, utility, and international comparability of DSPs and ICISS.

METHODS

Australia, Argentina, Austria, Canada, Denmark, New Zealand, and Sweden provided ICD-10-coded injury hospital discharge data, including in-hospital mortality status. Data from the seven countries were pooled using four different methods to create an international collaborative effort ICISS (ICE-ICISS). The ability of the ICISS to predict mortality using the country-specific DSPs and the pooled DSPs was estimated and compared.

RESULTS

The pooled DSPs were based on a total of 3,966,550 observations of injury diagnoses from the seven countries. The proportion of injury diagnoses having at least 100 discharges to calculate the DSP varied from 12% to 48% in the country-specific data set and was 66% in the pooled data set. When compared with using a country's own DSPs for ICISS calculation, the pooled DSPs resulted in somewhat reduced discrimination in predicting mortality (difference in c statistic varied from 0.006 to 0.04). Calibration was generally good when the predicted mortality risk was less than 20%. When Danish and Swedish data were used, ICISS was combined with age and sex in a logistic regression model to predict in-hospital mortality. Including age and sex improved both discrimination and calibration substantially, and the differences from using country-specific or pooled DSPs were minor.

CONCLUSION

Pooling data from seven countries generated empirically derived DSPs. These pooled DSPs facilitate international comparisons and enables the use of ICISS in all settings where ICD-10 hospital discharge diagnoses are available. The modest reduction in performance of the ICE-ICISS compared with the country-specific scores is unlikely to outweigh the benefit of internationally comparable Injury Severity Scores possible with pooled data.

LEVEL OF EVIDENCE

Prognostic and epidemiological study, level III.

The epidemiology of life-threatening work-related injury--a demonstration paper

BACKGROUND

Workers' compensation (WC) data traditionally provides information to stakeholders on work-related disabling injuries. It is important to complement this with information on serious threat to life (TTL) injury, which is the focus of this paper.

METHODS

In this cross-sectional descriptive epidemiological study, based on New Zealand's WC data linked to hospital discharge data, TTL was measured using the ICD10-based Injury Severity Score (ICISS); ICISS ≤ 0.941 was used to define serious TTL injury.

RESULTS

During 2002-2004, there was an average of 368 serious TTL work-related injury cases annually. The distribution of these injuries was very different from those traditionally found using WC data to describe disabling injury. For example, for serious TTL injury the main injury types included traumatic brain injury, whereas for disabling injury it was sprains and dislocations.

CONCLUSIONS

The method presented provides the opportunity for government agencies to produce a national description of the epidemiology of serious TTL work-related injuries.

An outcome evaluation of a New Zealand farm safety intervention: a historical cohort study

BACKGROUND

There is limited evidence that farm safety-related interventions based solely on an educational element have an effect on injury rates. Our aim was to evaluate a New Zealand national educational program, FarmSafe™ Awareness, for its effect on injury rates.

METHODS

We used a before-after design followed by a historical cohort study of sheep, beef, and dairy farmers/workers. The outcomes were work-related injuries, identified from workers compensation data. Cox regressions were used to compare intervention with matched control group rates.

RESULTS

FarmSafe™ Awareness was associated with significantly higher rates of work-related injury, than matched controls.

CONCLUSIONS

It is difficult to see how FarmSafe™ Awareness could be causing an increased rate of work-related injury. We detected no reporting bias, and selection bias is likely to act in the opposite direction to the observed results. We conclude that there is no evidence that FarmSafe™ Awareness prevents farm injury.

A standardised mortuary-based injury surveillance system: lessons learned from the Ibadan Nigerian trial

This study explored the challenges in establishing a mortuary-based injury surveillance system in a resource-constrained setting of Ibadan, Nigeria. To quantify and detail fatal injuries, in September 2010 to February 2011, a prospective data collection utilised the World Health Organization-Monash draft surveillance system. Findings were compared with other low- and middle-income settings, and surveillance system attributes were assessed. The leading injury mechanism among all age groups was transport related, with 45.6% being vulnerable road users, consistent with comparable settings. Fire-related injury was the second unintentional cause in the Ibadan pilot, unlike Global Burden of Disease estimates for Nigeria, Mauritius and Mexico, where drowning was the second cause. Positive system attributes included timeliness, data field completeness, specificity, flexibility and sensitivity. Despite apparent under-reporting of eligible deaths and questionable representativeness, this study illustrates potential for mortuary data to inform injury prevention policies and programmes in resource-constrained settings.

Trends in head injuries associated with mandatory bicycle helmet legislation targeting children and adolescents

BACKGROUND

Bicycling related head injuries (HIs) can be severe. Helmet use reduces head injury risk; however, there are few controlled studies of the effect of helmet legislation. We conducted this study to investigate changes in HIs after bicycle helmet legislation targeting those <18 in Alberta, Canada in 2002.

METHODS

Bicyclist and pedestrian (control) HI rates and HIs as a proportion of all injuries were compared for the three years (1999-2001) before and four years (2003-2006) after bicycle helmet legislation in three age groups (children: <13, adolescents: 13-17, and adults: 18+).

RESULTS

There were 41,270 ED visits and 2782 hospitalizations for bicyclists and 9836 ED visits and 2029 hospitalizations for pedestrians (excluding the legislation year 2002). The rate of ED HIs declined for child bicyclists and child pedestrians, while the rate of non-HIs declined in adult bicyclists and child pedestrians. The rate of hospitalized HIs declined in child bicyclists and all ages of pedestrians while non-HI rates declined for child and adult pedestrians. Non-HI rates for adolescent and adult bicyclists increased. After adjusting for sex and location, the proportion of ED bicycle HIs declined by 9% (APR=0.91; 95% CI: 0.86, 0.95) in children, was unchanged among adolescents and increased in adults (APR=1.08; 95% CI: 1.01, 1.15). The proportion of bicycle HI related hospitalizations decreased by 30% (APR=0.70; 95% CI: 0.55, 0.90) in children, 36% (APR=0.64; 95% CI: 0.49, 0.84) in adolescents and 24% (APR=0.76; 95% CI: 0.63, 0.91) in adults. There were no observed changes in the proportion of pedestrian HIs resulting in ED visits or hospitalizations.

INTERPRETATION

Our data indicate significant declines in the proportion of child bicyclist ED HIs and child, adolescent and adult bicyclist HI hospitalizations. This is in contrast to no significant trends in the proportion of ED or hospitalized HIs among pedestrians and the unexpected increases in the proportion of ED HIs for adult bicyclists. Comparing bicyclist and pedestrian trends in the proportion of child and adolescent HIs suggests a bicycle helmet legislation effect.

In-Hospital Mortality and Unintentional Falls Among Older Adults in the United States

Purpose of the Study:

To estimate the odds of death associated with documented unintentional falls and acute care hospitalization among older adults in the United States.

Design and Method:

Data were abstracted from the 2005 Nationwide Inpatient Sample (NIS) and odds of death were modeled using logistic regression.

Results:

The age 65 and older fall rate per 1,000 discharges was 53.0 while the mortality rate for those who fell was 33.2. Older-old (odds ration [ OR] = 2.93; confidence interval [CI] = [2.50, 3.43]), men ( OR = 1.64, CI = [1.54, 1.75]), and non-White ( OR = 1.09; CI = [1.01, 1.19]) had higher odds of death compared to younger-old, women, and Whites. Additional comorbidity ( OR = 3.41, CI = [3.05, 3.82]), dehydration ( OR = 1.14; CI = [1.05, 1.25]) and intracranial fractures ( OR = 4.46; CI = [4.02, 4.95]) resulted in greater odds of death.

Implications:

Among older adults who experienced a fall and hospitalization, odds of mortality appear influenced by factors beyond injury severity related to falling. Additional research is necessary to delineate the mechanisms behind these phenomena to inform the public about falls-prevention programs.

Chronic heart failure: we are fighting the battle, but are we winning the war?

Heart failure represents an end-stage phenotype of a number of cardiovascular diseases and is generally associated with a poor prognosis. A number of organized battles fought over the last two to three decades have resulted in considerable advances in treatment including the use of drugs that interfere with neurohormonal activation and device-based therapies such as implantable cardioverter defibrillators and cardiac resynchronization therapy. Despite this, the prevalence of heart failure continues to rise related to both the aging population and better survival in patients with cardiovascular disease. Registries have identified treatment gaps and variation in the application of evidenced-based practice, including the use of echocardiography and prescribing of disease-modifying drugs. Quality initiatives often coupled with multidisciplinary, heart failure disease management promote self-care and minimize variation in the application of evidenced-based practice leading to better long-term clinical outcomes. However, to address the rising prevalence of heart failure and win the war, we must also turn our attention to disease prevention. A combined approach is required that includes public health measures applied at a population level and screening strategies to identify individuals at high risk of developing heart failure in the future.

Regional variations in pedal cyclist injuries in New Zealand: safety in numbers or risk in scarcity?

OBJECTIVE

To assess regional variations in rates of traffic injuries to pedal cyclists resulting in death or hospital inpatient treatment, in relation to time spent cycling and time spent travelling in a car.

METHODS

Cycling injuries were identified from the Mortality Collection and the National Minimum Dataset. Time spent cycling and time spent travelling as a driver or passenger in a car/van/ute/SUV were computed from National Household Travel Surveys. There are 16 census regions in New Zealand, some of which were combined for this analysis to ensure an adequate sample size, resulting in eight regional groups. Analyses were undertaken for 1996-99 and 2003-07.

RESULTS

Injury rates, per million hours spent cycling, varied widely across regions (11 to 33 injuries during 1996-99 and 12 to 78 injuries during 2003-07). The injury rate increased with decreasing per capita time spent cycling. The rate also increased with increasing per capita time spent travelling in a car. There was an inverse association between the injury rate and the ratio of time spent cycling to time spent travelling in a car. The expected number of cycling injuries increased with increasing total time spent cycling but at a decreasing rate particularly after adjusting for total time spent travelling in a car.

CONCLUSIONS

The findings indicate a 'risk in scarcity' effect for New Zealand cyclists such that risk profiles of cyclists are likely to deteriorate if fewer people use a bicycle and more use a car.

IMPLICATIONS

Cooperative efforts to promote cycling and its safety and to restrict car use may reverse the risk in scarcity effect.

Is the TMPM-ICD9 revolution in trauma risk-adjustment compatible with imperfect administrative coding?

BACKGROUND

TMPM-ICD9 is the latest injury-severity measure based on empirical estimation from ICD-9-CM codes. It is candidate to replace expert-based AIS measures worldwide because of easier accessibility and better predictive performances. In Italy and other countries administrative ICD coding is generally less complete than dedicated AIS coding. We attempted to ascertain how this affects TMPM performances.

METHODS

Discrimination (c statistics) and calibration (calibration curves, Akaike's criterion) of hierarchical logistic regression models for hospital mortality comprising TMPM or ISS were compared using trauma-registry data on 3570 patients of years 2007-2009. The completeness of AIS vs. ICD-9-CM coding was also investigated through the ratio of the respective numbers of codes per patient. Model discrimination was further analyzed after stratification according to the above ratio (>1 and ≤ 1).

RESULTS

The models with TMPM showed worse performances. The differences, concerned calibration (graphical evidence) in univariate models and discrimination (-1.2% of area under the ROC curve, p<0.05) in models completed with age, gender, mechanism of injury, motor GCS and systolic pressure. In parallel, ICD coding was less complete than AIS, as expected: 68% of patients had a ratio >1. The discrimination of TMPM vs. ISS models improved when the ratio changed from >1 to ≤ 1.

CONCLUSIONS

The predictive performances of TMPM-ICD9 vs. ISS were lower than in the previous studies; the sub-optimal quality of ICD coding was a main cause. Imperfect administrative coding may hence hamper the TMPM-ICD9 revolution, although in our setting the negligible differences and the ready availability of administrative data may still give reason for adopting TMPM-ICD9.

Assessing external cause of injury coding accuracy for transport injury hospitalizations

External cause of injury codes (E codes) capture circumstances surrounding injuries. While hospital discharge data are primarily collected for administrative/billing purposes, these data are secondarily used for injury surveillance. We assessed the accuracy and completeness of hospital discharge data for transport-related crashes using trauma registry data as the gold standard. We identified mechanisms of injury with significant disagreement and developed recommendations to improve the accuracy of E codes in administrative data. Overall, we linked 2,192 (99.9 percent) of the 2,195 discharge records to trauma registry records. General mechanism categories showed good agreement, with 84.7 percent of records coded consistently between registry and discharge data (Kappa 0.762, p < .001). However, agreement was lower for specific categories (e.g., ATV crashes), with discharge records capturing only 70.4 percent of cases identified in trauma registry records. Efforts should focus on systematically improving E-code accuracy and detail through training, education, and informatics such as automated data linkages to trauma registries.

A comparison of female and male adolescent victims of violence seen in the emergency department

BACKGROUND

Violence is a leading cause of injury and death among adolescents. Reports indicate increasing incidence of violent injuries among adolescent females, but have not described characteristics of or charting completeness for these assault victims in the emergency department (ED).

OBJECTIVES

To compare demographic and injury-related characteristics of assaulted urban adolescent females and males presenting to an ED; and to compare completeness of hospital coding for intentionality of females' and males' injuries.

METHODS

Retrospective, cross-sectional analysis of potentially violent injuries (identified by E-codes and chart review) among urban youth presenting to a city's only level I trauma center. Demographics, injury characteristics, and chart- vs. hospital-determined intentionality were described with proportions and relative risks.

RESULTS

E-code search resulted in 828 charts with injury diagnoses; 385 were determined by chart review to represent violent injuries (150 females, 235 males). Female victims had similar race, age, and socioeconomic status to males. Females' injuries were more likely to be documented as caused by a single person, by someone known to them, and at home. Females were less likely to be injured by weapons or in a public space. Females' charts were more likely to contain information about the circumstances of injury. Intentionality was equally likely to be miscoded for females and males.

CONCLUSIONS

Adolescent female victims of community violence presenting to an urban ED have different assault characteristics from males. Females' charts have less missing information. A high percentage of all charts have assault intentionality miscoded, suggesting that E-code-based violence surveillance in this population may not be accurate.

Hospitalisations and deaths due to unintentional cutting or piercing injuries at home amongst young and middle-aged New Zealanders

AIMS

To describe the incidence and characteristics of unintentional cutting or piercing injuries at home resulting in death or hospital inpatient treatment amongst young and middle-aged New Zealanders.

PATIENTS AND METHODS

Inpatient admissions amongst individuals aged 20–64 years with a primary diagnosis of cutting or piercing injury (ICD-9AM E code: E920, and ICD-10-AM E codes: W25–29, W45)and a length of stay of 24 h or more, were identified using the national morbidity (1997–2006) and mortality (1996–2005) databases compiled by the New Zealand Ministry of Health. Relevant data were extracted and analysed.

RESULTS

During the 10-year period (1997–2006) 21,559 people aged 20–64 years had a primary admission to hospital for an injury caused by unintentional cutting or piercing, 29% (6355) of which occurred at home. The place of injury was not identified in a further 43% (9293) of records. During the 10-year period (1996–2005) 25 people aged 20–64 years died of injuries of this nature, 18 of which occurred at home (in 2 cases the place of injury was not recorded). The hospitalisation rate following cutting or piercing at home was 24.9 per 100,000. For every death there were 352 admissions to hospital, with rates of admission almost two-fold greater amongst 20–24 year olds compared to those aged 60–64 years.

CONCLUSION

Almost 30% of unintentional cutting or piercing related injuries amongst young and middle aged adults occur at home. Whilst death is uncommon, the causes and preventability of the high numbers of hospitalisations, particularly amongst young adults, require research attention.

Can poison control data be used for pharmaceutical poisoning surveillance?

OBJECTIVE

To determine the association between the frequencies of pharmaceutical exposures reported to a poison control center (PCC) and those seen in the emergency department (ED).

DESIGN

A statewide population-based retrospective comparison of frequencies of ED pharmaceutical poisonings with frequencies of pharmaceutical exposures reported to a regional PCC. ED poisonings, identified by International Classification of Diseases, Version 9 (ICD-9) codes, were grouped into substance categories. Using a reproducible algorithm facilitated by probabilistic linkage, codes from the PCC classification system were mapped into the same categories. A readily identifiable subset of PCC calls was selected for comparison.

MEASUREMENTS

Correlations between frequencies of quarterly exposures by substance categories were calculated using Pearson correlation coefficients and partial correlation coefficients with adjustment for seasonality.

RESULTS

PCC reported exposures correlated with ED poisonings in nine of 10 categories. Partial correlation coefficients (r(p)) indicated strong associations (r(p)>0.8) for three substance categories that underwent large changes in their incidences (opiates, benzodiazepines, and muscle relaxants). Six substance categories were moderately correlated (r(p)>0.6). One category, salicylates, showed no association. Limitations Imperfect overlap between ICD-9 and PCC codes may have led to miscategorization. Substances without changes in exposure frequency have inadequate variability to detect association using this method.

CONCLUSION

PCC data are able to effectively identify trends in poisonings seen in EDs and may be useful as part of a pharmaceutical poisoning surveillance system. The authors developed an algorithm-driven technique for mapping American Association of Poison Control Centers codes to ICD-9 codes and identified a useful subset of poison control exposures for analysis.

Do we have enough information? How ICD-10-AM Activity codes measure up

This research explored the usage of activity codes introduced into the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian Modification (ICD-10-AM) Third Edition and examined the data quality of activity coding, explicitly, completeness and specificity. Injury separations for years 2001/02 to 2005/06 specifying a 'true injury' were extracted for descriptive analyses. Part A investigated the usage of activity codes and compared the usage of the 236 activity codes available in the Activity block (U50-U73) present in the ICD-10-AM Third Edition against the 16 codes present in the second edition. Part B examined the level of completeness of external cause coding and the degree of activity coding specificity in the 2005/06 dataset. It was found that the additional activity codes were used extensively with only 46 codes seldom assigned. Codes present in the second edition were extensively used in the third and fourth editions and the new additional activity codes represent 10% of all activity codes assigned per year. All five datasets demonstrated high levels of completeness, recording completeness levels greater than 97%, where missing activity codes attributed to the majority of missing codes. Fourteen out of the 24 activity categories demonstrated a strong reliance on non-specific codes and Team ball sports and Wheeled non-motor sports illustrated that activity codes assigned lacked detail in the code. Clinicians and coders need to acknowledge the importance of quality clinical documentation for research and policy-making purposes so that circumstances surrounding injury events can be coded to the highest level of specificity to improve injury prevention and control activities. Missing activity codes and the abundance of non-specific coding hinders the usefulness of the data.

Adverse drug reactions related hospital admissions in persons aged 60 years and over, The Netherlands, 1981-2007: less rapid increase, different drugs

BACKGROUND

Epidemiologic information on time trends of Adverse Drug Reactions (ADR) and ADR-related hospitalizations is scarce. Over time, pharmacotherapy has become increasingly complex. Because of raised awareness of ADR, a decrease in ADR might be expected. The aim of this study was to determine trends in ADR-related hospitalizations in the older Dutch population.

METHODOLOGY AND PRINCIPAL FINDINGS

Secular trend analysis of ADR-related hospital admissions in patients ≥60 years between 1981 and 2007, using the National Hospital Discharge Registry of The Netherlands. Numbers, age-specific and age-adjusted incidence rates (per 10,000 persons) of ADR-related hospital admissions were used as outcome measures in each year of the study. Between 1981 and 2007, ADR-related hospital admissions in persons ≥60 years increased by 143%. The overall standardized incidence rate increased from 23.3 to 38.3 per 10,000 older persons. The increase was larger in males than in females. Since 1997, the increase in incidence rates of ADR-related hospitalizations flattened (percentage annual change 0.65%), compared to the period 1981-1996 (percentage annual change 2.56%).

CONCLUSION/SIGNIFICANCE

ADR-related hospital admissions in older persons have shown a rapidly increasing trend in The Netherlands over the last three decades with a temporization since 1997. Although an encouraging flattening in the increasing trend of ADR-related admissions was found around 1997, the incidence is still rising, which warrants sustained attention to this problem.

Injuries to pedal cyclists on New Zealand roads, 1988-2007

BACKGROUND

The risk of injury is one of the major barriers to engaging in cycling. We investigated exposure-based rates and profiles of traffic injuries sustained by pedal cyclists that resulted in death or hospital inpatient treatment in New Zealand, one of the most car dependent countries.

METHODS

Pedal cyclist traffic injuries were identified from the Mortality Collection and the National Minimum Dataset. Total time spent cycling was used as the measure of exposure and computed from National Household Travel Surveys. Analyses were undertaken for the periods 1988-91, 1996-99 and 2003-07 in relation to other major road users and by age, gender and body region affected. A modified Barell matrix was used to characterise the profiles of pedal cyclist injuries by body region affected and nature of injury.

RESULTS

Cyclists had the second highest rate of traffic injuries compared to other major road user categories and the rate increased from 1996-99 to 2003-07. During 2003-07, 31 injuries occurred per million hours spent cycling. Non-collision crashes (40%) and collisions with a car, pick-up truck or van (26%) accounted for two thirds of the cycling injuries. Children and adolescents aged under 15 years were at the highest risk, particularly of non-collision crashes. The rate of traumatic brain injuries fell from 1988-91 to 1996-99; however, injuries to other body parts increased steadily. Traumatic brain injuries were most common in collision cases whereas upper extremity fractures were most common in other crashes.

CONCLUSIONS

The burden of fatal and hospitalised injuries among pedal cyclists is considerable and has been increasing over the last decade. This underscores the development of road safety and injury prevention programmes for cyclists alongside the cycling promotion strategies.

ISS mapped from ICD-9-CM by a novel freeware versus traditional coding: a comparative study

Background

Injury severity measures are based either on the Abbreviated Injury Scale (AIS) or the International Classification of diseases (ICD). The latter is more convenient because routinely collected by clinicians for administrative reasons. To exploit this advantage, a proprietary program that maps ICD-9-CM into AIS codes has been used for many years. Recently, a program called ICDPIC trauma and developed in the USA has become available free of charge for registered STATA^® users. We compared the ICDPIC calculated Injury Severity Score (ISS) with the one from direct, prospective AIS coding by expert trauma registrars (dAIS).

Methods

The administrative records of the 289 major trauma cases admitted to the hospital of Udine-Italy from 1 July 2004 to 30 June 2005 and enrolled in the Italian Trauma Registry were retrieved and ICDPIC-ISS was calculated. The agreement between ICDPIC-ISS and dAIS-ISS was assessed by Cohen's Kappa and Bland-Altman charts. We then plotted the differences between the 2 scores against the ratio between the number of traumatic ICD-9-CM codes and the number of dAIS codes for each patient (DIARATIO). We also compared the absolute differences in ISS among 3 groups identified by DIARATIO. The discriminative power for survival of both scores was finally calculated by ROC curves.

Results

The scores matched in 33/272 patients (12.1%, k 0.07) and, when categorized, in 80/272 (22.4%, k 0.09). The Bland-Altman average difference was 6.36 (limits: minus 22.0 to plus 34.7). ICDPIC-ISS of 75 was particularly unreliable. The differences increased (p < 0.01) as DIARATIO increased indicating incomplete administrative coding as a cause of the differences. The area under the curve of ICDPIC-ISS was lower (0.63 vs. 0.76, p = 0.02).

Conclusions

Despite its great potential convenience, ICPIC-ISS agreed poorly with its conventionally calculated counterpart. Its discriminative power for survival was also significantly lower. Incomplete ICD-9-CM coding was a main cause of these findings. Because this quality of coding is standard in Italy and probably in other European countries, its effects on the performances of other trauma scores based on ICD administrative data deserve further research. Mapping ICD-9-CM code 862.8 to AIS of 6 is an overestimation.

Hip fracture incidence in relation to age, menopausal status, and age at menopause: prospective analysis

BACKGROUND

Bone mineral density is known to decrease rapidly after the menopause. There is limited evidence about the separate contributions of a woman's age, menopausal status and age at menopause to the incidence of hip fracture.

METHODS AND FINDINGS

Over one million middle-aged women joined the UK Million Women Study in 1996-2001 providing information on their menopausal status, age at menopause, and other factors, which was updated, where possible, 3 y later. All women were registered with the UK National Health Service (NHS) and were routinely linked to information on cause-specific admissions to NHS hospitals. 561,609 women who had never used hormone replacement therapy and who provided complete information on menopausal variables (at baseline 25% were pre/perimenopausal and 75% postmenopausal) were followed up for a total of 3.4 million woman-years (an average 6.2 y per woman). During follow-up 1,676 (0.3%) were admitted to hospital with a first incident hip fracture. Among women aged 50-54 y the relative risk (RR) of hip fracture risk was significantly higher in postmenopausal than premenopausal women (adjusted RR 2.22, 95% confidence interval [CI] 1.22-4.04; p = 0.009); there were too few premenopausal women aged 55 y and over for valid comparisons. Among postmenopausal women, hip fracture incidence increased steeply with age (p<0.001), with rates being about seven times higher at age 70-74 y than at 50-54 y (incidence rates of 0.82 versus 0.11 per 100 women over 5 y). Among postmenopausal women of a given age there was no significant difference in hip fracture incidence between women whose menopause was due to bilateral oophorectomy compared to a natural menopause (adjusted RR 1.20, 95% CI 0.94-1.55; p = 0.15), and age at menopause had little, if any, effect on hip fracture incidence.

CONCLUSIONS

At around the time of the menopause, hip fracture incidence is about twice as high in postmenopausal than in premenopausal women, but this effect is short lived. Among postmenopausal women, age is by far the main determinant of hip fracture incidence and, for women of a given age, their age at menopause has, at most, a weak additional effect. Please see later in the article for the Editors' Summary.

Development and validation of the Excess Mortality Ratio-adjusted Injury Severity Score Using the International Classification of Diseases 10th Edition

OBJECTIVES

This study aimed to develop and validate a new method for measuring injury severity, the excess mortality ratio-adjusted Injury Severity Score (EMR-ISS), using the International Classification of Diseases 10th Edition (ICD-10).

METHODS

An injury severity grade similar to the Abbreviated Injury Scale (AIS) was converted from the ICD-10 codes on the basis of quintiles of the EMR for each ICD-10 code. Like the New Injury Severity Score (NISS), the EMR-ISS was calculated from three maximum severity grades using data from the Korean National Injury Database. The EMR-ISS was then validated using the Hosmer-Lemeshow goodness-of-fit chi-square (HL chi-square, with lower values preferable), the area under the receiver operating characteristic curve (AUC-ROC), and the Pearson correlation coefficient to compare it with the International Classification of Diseases 9th Edition-based Injury Severity Score (ICISS). Nationwide hospital discharge abstract data (DAD) from stratified-sample general hospitals (n = 150) in 2004 were used for an external validation.

RESULTS

The total number of study subjects was 29,282,531, with five subgroups of particular interest identified for further study: traumatic brain injury (TBI, n = 3,768,670), traumatic chest injury (TCI,n = 1,169,828), poisoning (n = 251,565), burns (n = 869,020), and DAD (n = 26,374). The HL chi-square was lower for EMR-ISS than for ICISS in all groups: 42,410.8 versus 55,721.9 in total injury, 7,139.6 versus 20,653.9 in TBI, 6,603.3 versus 4,531.8 in TCI, 2,741.2 versus 9,112.0 in poisoning, 764.4 versus 4,532.1 in burns, and 28.1 versus 49.4 in DAD. The AUC-ROC for death was greater for EMR-ISS than for ICISS: 0.920 versus 0.728 in total injury, 0.907 versus 0.898 in TBI, 0.675 versus 0.799 in TCI, 0.857 versus 0.900 in poisoning, 0.735 versus 0.682 in burns, and 0.850 versus 0.876 in DAD. The Pearson correlation coefficient between the two scores was )0.68 in total injury, )0.76 in TBI, )0.86 in TCI, )0.69 in poisoning,)0.58 in burns, and )0.75 in DAD.

CONCLUSIONS

The EMR-ISS showed better calibration and discrimination power for prediction of death than the ICISS in most injury groups. The EMR-ISS appears to be a feasible tool for passive injury surveillance of large data sets, such as insurance data sets or community injury registries containing diagnosis codes. Additional further studies for external validation on prospectively collected data sets should be considered.

Validity of police-reported information on injury severity for those hospitalized from motor vehicle traffic crashes

OBJECTIVE

The objective of this study was to assess the validity of police-reported information on the severity of injury for non-fatal motor vehicle traffic crashes (crashes) in New Zealand that resulted in hospitalization.

METHODS

Details of crashes reported to the police resulting in non-fatal injury in New Zealand from January 2000 to December 2004 were obtained from Land Transport New Zealand Traffic crash reports (crash reports). Data about individuals' injuries were matched to New Zealand Health Information Service hospital discharge data. A severity score was assigned to the hospital International Classification of Diseases-10 (ICD-10) diagnosis codes, using a threat-to-life tool, the ICD-based Injury Severity Score (ICISS).

RESULTS

Of the linked data, 49.3 percent of crash victims were recorded by police as having "serious" injuries on the crash report but given the police definition of serious injury, all 14,869 records should have been recorded as serious on the crash report. Of these, only 48 percent had an injury with a significant threat to life. Fifteen percent of those with a "minor" injury on the crash report had an injury with a significant threat to life.

CONCLUSIONS

The subjective police assessment of severity of injury was discordant in many instances with an objective measure of severity. There was variation in the concordance by personal, vehicle, and crash variables. This has implications for interpreting New Zealand's road safety statistics, the assessment of road safety programs, and the allocation of funding to target specific road safety problems.

Completeness and accuracy of International Classification of Disease (ICD) external cause of injury codes in emergency department electronic data

The accuracy of external cause of injury codes (E codes) for work-related and non-work-related injuries in Massachusetts emergency department data were evaluated. Medical records were reviewed and coded by a nosologist with expertise in E coding for a stratified random sample of 1000 probable work-related (PWR) and 250 probable non-work-related (PNWR) cases. Cause of injury E codes were present for 98% of reviewed cases and accurate for 65% of PWR cases and 57% of PNWR cases. Place of occurrence E codes were present in less than 30% of cases. Broad cause of injury categories were accurate for about 85% of cases. Non-specific categories (not elsewhere classified, not specified) accounted for 34% of broad category misclassifications. Among specified causes, machinery injuries were misclassified most often (39/60, 65%), predominantly as cut/pierce or struck by/against. E codes reliably identify the broad mechanism of injury, but inaccuracies and incompleteness suggest areas for training of hospital admissions staff, providers, and coders.

Coding external causes of injuries: problems and solutions

Complete and accurate information about hospitalised injuries is essential for injury risk and outcome research, though the accuracy and reliability of hospital data for injury surveillance are often questioned. To ascertain clinical coders' views of the reasons for a lack of specificity in external cause code usage and ways to improve external cause coding, a nationwide survey of coders was conducted in Australia in 2006. Four hundred and two coders participated in the questionnaire. The results of this study show that discharge summaries and doctors' notes were the poorest source of information regarding external causes, place of injury occurrence, and activity at the time of injury. Coders viewed missing external cause information and missing documentation as having the greatest impact on the quality of external cause coding. A large majority of coders suggested that improving clinical documentation in the emergency department and introducing a centralised structured form for external cause information would improve the quality of external cause coding. Clinical coders are a valuable source of information regarding problems with, and solutions to the collection of high quality data and this research has highlighted several areas where improvements can be made and further research is needed.

Unspecified falls among youth: predictors of coding specificity in the emergency department

BACKGROUND

Deficiencies in emergency department (ED) charting is a common international problem. While unintentional falls account for the largest proportion of injury related ED visits by youth, insufficient charting details result in more than one third of these falls being coded as "unspecified". Non-specific coding compromises the utility of injury surveillance data.

OBJECTIVE

To re-examine the ED charts of unspecified youth falls to determine the possibility of assigning more specific codes.

METHODS

400 ED charts for youth (aged 0-19 years) treated at four EDs in an urban Canadian health region between 1997 and 1999 and coded as "Other or unspecified fall" (ICD-9 E888) were randomly selected. A structured chart review was completed and a blinded nosologist recoded the cause of injury using the extracted data. Differences in coding specificity were compared with the original data, and logistic regression was undertaken to examine variables that predicted assignment of a specific E-code.

RESULTS

A more specific code was assigned to 46% of cases initially coded as unspecified. Of these, 73% were recoded as "Slips, trips, and stumbles" (E885), which still lacks the specificity required for injury prevention planning; 2% of charts had no fall documented. Multivariate analysis revealed that dichotomized injury severity (adjusted odds ratio (OR) = 1.75 (95% confidence interval, 1.11 to 2.78)), arrival at the ED by ambulance (adjusted OR = 5.41 (1.07 to 27.0)), and the availability of nurse's notes or triage forms, or both, in the chart (adjusted OR = 3.75 (2.17 to 6.45)) were the strongest predictors of a more specific E-code assignment.

CONCLUSIONS

Deficiencies in both chart documentation and coding specificity contribute to the use of non-specific E-codes. More comprehensive triage coding, improved chart documentation, and alternative methods of data collection in the acute care setting are required to improve ED injury surveillance initiatives.

Hospitalisations and deaths due to unintentional falls at home among working-aged New Zealanders

AIMS

To describe the incidence and characteristics of unintentional fall-related injuries at home resulting in death or hospital inpatient treatment among working-aged New Zealanders.

PATIENTS AND METHODS

Relevant data on all individuals aged 25-59 years meeting the case definition (using ICD-9-AM E codes E880-886, 888, and ICD-10-AM E codes W00-19) were obtained from the national morbidity (1993-2004) and mortality (1993-2002) databases compiled by the New Zealand Health Information Service.

RESULTS

Almost one-third of unintentional falls resulting in injury and a subsequent in-patient admission among working-age people were reported to occur at home. This is likely to be an underestimate as the place of occurrence of approximately one-third of falls resulting in a hospital admission was not documented. The average annual mortality rate from unintentional falls at home was 0.41 per 100,000 (95% CI 0.32-0.51) while the primary hospitalisation rate was more than 100-fold greater at 52.0 per 100,000 (95% CI 51.1-53.0). Rates of admission to hospital following a fall at home were three to four-fold greater among people aged 55-59 years compared to those aged 25-29 years.

CONCLUSION

A significant proportion of unintentional fall-related injuries among the working-age population occur at home. Until the aetiology of fall-related injury in this age group is better understood, future research should focus on identifying modifiable risk factors that can be targeted to reduce the burden of these injuries and their consequences in a context where the adverse impact on economic productivity is particularly high.

Completeness of cause of injury coding in healthcare administrative databases in the United States, 2001

OBJECTIVES

To determine the completeness of external cause of injury coding (E-coding) within healthcare administrative databases in the United States and to identify factors that contribute to variations in E-code reporting across states.

DESIGN

Cross sectional analysis of the 2001 Healthcare Cost and Utilization Project (HCUP), including 33 State Inpatient Databases (SID), a Nationwide Inpatient Sample (NIS), and nine State Emergency Department Databases (SEDD). To assess state reporting practices, structured telephone interviews were conducted with the data organizations that participate in HCUP.

RESULTS

The percent of injury records with an injury E-code was 86% in HCUP's nationally representative database, the NIS. For the 33 states represented in the SID, completeness averaged 87%, with more than half of the states reporting E-codes on at least 90% of injuries. In the nine states also represented in the SEDD, completeness averaged 93%. Twenty two states had mandates for E-code reporting, but only eight had provisions for enforcing the mandates. These eight states had the highest rates of E-code completeness.

CONCLUSIONS

E-code reporting in administrative databases is relatively complete, but there is significant variation in completeness across the states. States with mandates for the collection of E-codes and with a mechanism to enforce those mandates had the highest rates of E-code reporting. Nine statewide ED data systems demonstrate consistently high E-coding completeness.

Developing valid indicators of injury incidence for "all injury"

BACKGROUND/AIMS

This paper focuses on the methods used to develop indicators for "all injury" incidence for the New Zealand Injury Prevention Strategy (NZIPS), launched in June 2003. Existing and previously proposed New Zealand national non-fatal injury indicators exhibited threats to validity. Population/

SETTING

The total population of New Zealand.

METHODS

The authors proposed fatal and new non-fatal injury indicators for "all injury" based on national mortality and hospitalizations data. All of the candidate indicators were subjected to a systematic assessment of validity, using the International Collaborative Effort on Injury Statistics (ICE) criteria. Based on the results of that validation, the authors identified four proposed NZIPS indicators.

RESULTS

The proposed "all injury" indicators were as follows: age standardized injury mortality rate per 100 000 person-years at risk; number of injury deaths; age standardized serious non-fatal injury rate per 100 000 person-years at risk; and number of cases of serious non-fatal injury. The authors identified no threat-to-validity when assessed against the ICE criteria. The estimated numbers and rates of serious non-fatal injury increased over the period, in contrast to the numbers and rates of fatal injury.

CONCLUSION

The authors have proposed serious non-fatal injury indicators that they judge suffer substantially less bias than traditional non-fatal injury indicators. This approach to indicator development is consistent with the view that before newly proposed indicators are promulgated, they should be subjected to formal validation. The authors are encouraged that the New Zealand Government has accepted these arguments and proposed indicators, and are starting to act on some of their recommendations, including the development of complementary indicators.